Acute Crystal Arthritis in NSAID-Allergic Patients
First-Line Recommendation
For a 40-year-old woman with acute crystal arthritis and true NSAID allergy, systemic glucocorticosteroids are the treatment of choice: prednisone 0.5 mg/kg/day for 5–10 days provides rapid symptom control with the best benefit-risk profile when NSAIDs are contraindicated. 1, 2
Treatment Algorithm for NSAID-Allergic Patients
Option 1: Intra-articular Approach (Preferred for Mono- or Oligoarticular Disease)
Joint aspiration combined with intra-articular triamcinolone acetonide 60 mg is the gold-standard therapy for acute crystal arthritis affecting one or a few joints, providing rapid local relief while avoiding systemic drug exposure. 1, 3
This approach simultaneously confirms crystal diagnosis under polarized microscopy and excludes septic arthritis—critical because injecting steroids into an infected joint can be catastrophic. 3, 2
Adjunctive ice application and brief joint rest after injection further enhance symptom control. 3
This is the highest-strength recommendation from EULAR guidelines and should be attempted whenever technically feasible. 3
Option 2: Systemic Glucocorticosteroids (When Intra-articular Injection Is Not Feasible)
Oral Regimen
Prednisone or prednisolone 0.5 mg/kg/day for 5–10 days, then discontinue without taper if the course is short (≤10 days). 1, 2
Alternative regimen: full dose for 2–5 days, then taper over 7–10 days before discontinuation. 1, 2
An oral methylprednisolone dose pack is also appropriate based on current practice patterns. 2
Parenteral Regimen
Single intramuscular triamcinolone acetonide 60 mg produces ≥50% clinical improvement in all patients within 14 days. 1, 3
Single-dose parenteral betamethasone 7 mg IM or methylprednisolone 125 mg IV yields faster pain control (NNT = 3 on day 1) compared with NSAIDs. 1
Parenteral ACTH 40–80 units administered three times resolves acute attacks in a mean of 4.2 days, with only mild metabolic side effects (hypokalemia, hyperglycemia). 1, 3
Methylprednisolone IM is FDA-approved for acute gouty arthritis and rheumatic disorders, making it a legitimate option for crystal-induced arthritis. 4
Option 3: Colchicine (Alternative When Steroids Are Contraindicated)
Low-dose colchicine 0.5 mg three to four times daily (with or without a 1 mg loading dose) is effective for acute attacks but less potent than steroids. 1, 3
Traditional high-dose regimens (1 mg loading then 0.5 mg every 2 hours) should be avoided because they cause marked side effects in 100% of patients. 1
Intravenous colchicine is absolutely contraindicated due to serious toxicity and risk of fatal outcomes. 1
Colchicine carries a risk of diarrhea and drug interactions, particularly in elderly patients with polypharmacy. 3
In severe renal impairment (CrCl <30 mL/min), reduce colchicine dose to 0.3 mg/day. 1, 2
Why Steroids Are Optimal in This Patient
Prednisone provides the best benefit-risk ratio for acute crystal arthritis, particularly when NSAIDs are contraindicated. 5
At age 40, this patient is younger than the typical CPPD population, but systemic steroids remain the safest systemic option when NSAIDs are unavailable. 1, 2
Evidence for steroid efficacy is extrapolated from gout studies (Level IIb-III), but clinical experience strongly supports their use in all forms of crystal arthritis. 3, 2
Critical Pitfalls to Avoid
Never assume infection is excluded without joint aspiration in monoarticular presentations before steroid injection—septic arthritis must be ruled out. 3, 2
Do not use prolonged steroid courses without a clear tapering plan, as this increases adverse effects without additional benefit. 2
Avoid high-molecular-weight hyaluronan intra-articular injections, as they can precipitate acute CPPD attacks. 1, 3
Do not treat asymptomatic chondrocalcinosis—it is an age-related finding requiring no intervention. 1, 3
Prophylaxis for Recurrent Attacks (If Needed)
Low-dose colchicine 0.5–1.0 mg daily reduces attack frequency from 3.2 to 1.0 episodes per year (p <0.001) and benefits approximately 90% of patients. 1
Prophylaxis is indicated only for patients with documented recurrent attacks, not for asymptomatic chondrocalcinosis. 3